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Management of Cluster Headache

ELLEN BECK, M.D., WILLIAM J. SIEBER, PH.D., and RAL TREJO, M.D.
University of California, San Diego, La Jolla, California

Cluster headache, an excruciating, unilateral headache usually accompanied by conjunctival


injection and lacrimation, can occur episodically or chronically, and can be difficult to treat. Existing effective treatments may be underused because of underdiagnosis of the syndrome. Oxygen
and sumatriptan have been demonstrated to be effective in the acute treatment of cluster headaches. Verapamil has been shown to be effective for prophylaxis. For cluster headache completely
refractory to all treatments, surgical modalities and newer interventions such as the implantation
of stereotactic electrodes may be useful. Patients should be encouraged to avoid possible triggers
such as smoking or alcohol consumption, especially during the cluster period. The intensity of
cluster headache pain leads to ethical concerns among researchers over the use of placebo, making
randomized controlled trials difficult. As new technology and genetic studies clarify the etiology
of cluster headache, it is possible that more specific therapies will emerge. (Am Fam Physician
2005;71:717-24,728. Copyright 2005 American Academy of Family Physicians.)

Patient information:
A handout on cluster
headaches, written by the
authors of this article, is
provided on page 728.
See page 639 for strengthof-recommendation labels.

he diagnosis and optimal management of cluster headache remain


challenging. This most painful of
primary headaches affects 0.1 percent of adults.1 The male-to-female ratio
has diminished from 6.2 to 1 in the 1960s to
2.1 to 1 in the 1990s.2 Men may first experience cluster headache in their early 20s,
with peak onset in their 40s. In one study,3
the most frequent age at onset for women
was in their 60s. Cluster headache may be
underdiagnosed in black women,4 but ethnic
differences in prevalence have not been studied. Having a family history of headaches,
smoking, head injury, or shift work has been
associated with cluster headache.

Clinical Features and Classification


In 2004, the International Headache Society
published new criteria for diagnosing cluster
headache. To fulfill criteria for diagnosis,
patients must have had at least
five attacks occurring from one
Restlessness and agitated
every other day to eight per day;
behavior are reported
and attributable to no other dissymptoms in 93 percent of
order.5 In addition, headaches
cluster headache patients.
must cause severe or very severe
unilateral orbital, supraorbital,
or temporal pain lasting 15 to 180 minutes
if untreated, and be accompanied by one or
more of the following: ipsilateral conjunctival injection or lacrimation, ipsilateral nasal
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congestion or rhinorrhea, ipsilateral eyelid


edema, ipsilateral forehead and facial sweating, ipsilateral miosis or ptosis, or a sense of
restlessness or agitation.5 Episodic cluster
headache is defined as at least two cluster
periods lasting seven to 365 days and separated by pain-free remission periods of one
month or longer. Chronic attacks recur over
more than one year without remission or
with remission lasting less than one month.5
Called suicide headache because of its
severity and alarm clock headache because
of its periodicity, cluster headache is characterized by unilateral excruciating pain
(a hot-poker or stabbing sensation) in the
ocular, frontal, or temporal areas. Pain often
radiates to the upper teeth, jaw, and neck.
Associated signs include ptosis, ipsilateral
lacrimation, conjunctival injection, and rhinorrhea. The pain usually is unilateral, with
60 percent of patients reporting headaches
on the right side, but 14 percent of patients
report a side shift during an attack, and
18 percent report involvement of different
sides in subsequent attacks.6
Other symptoms include facial flushing
or pallor, tenderness on palpation of the
ipsilateral carotid artery, bradycardia, and
abnormal feeling of scalp hairs. The absence
of aura, nausea, or vomiting has helped distinguish cluster from migraine headaches,
but recent studies indicate that 14 percent
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Strength of Recommendations
Key clinical recommendation

Label

References

The first-line treatments for acute cluster headache


are oxygen or sumatriptan, or a combination of
the two.

15-18

Less well studied alternatives for acute treatment


include intranasal dihydroergotamine, intranasal
lidocaine, and intranasal capsaicin.

19-21

Verapamil, in a dosage of 360 to 480 mg daily, can


effectively reduce the number of attacks during a
cluster headache period.

24, 26

Less well studied alternatives for prophylaxis include


prednisone and antiepileptic drugs; they should only
be considered if verapamil is not tolerated or not
effective.

26, 32, 28

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limitedquality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
practice, opinion, or case series. See page 639 for more information.

of patients with cluster headache experience


aura, 51 percent have a personal or family
history of migraine, 56 percent report photophobia, 43 percent report phonophobia,
and 23 percent report osmophobia.7 Thus,
the presence of aura, nausea, vomiting, or
photophobia should not rule out a diagnosis
of cluster headache.8 A characteristic feature
of cluster headache, noted by 93 percent of
patients in one study,7 is restlessness, with
behaviors such as pacing and rocking the
head and trunk with head in hands.9 Most
of these headaches last 15 minutes to three
hours and recur at the same time of day,
The Authors
ELLEN BECK, M.D., is director of community education in the Division of
Family Medicine in the Department of Family & Preventive Medicine at the
University of California, San Diego (UCSD), School of Medicine, in La Jolla. She
is director of the UCSD student free clinic project and a clinician at La Maestra
community health center in San Diego. She received her medical degree from
McGill University and completed a family medicine residency at Jewish General
Hospital, both in Montreal, Quebec.
WILLIAM J. SIEBER, PH.D., is assistant clinical professor in the Department of
Family & Preventive Medicine at UCSD. He earned a doctoral degree in clinical
psychology from Yale University.
RAL TREJO, M.D., is faculty in the Scripps Chula Vista family practice residency
and Department of Family & Preventive Medicine at UCSD School of Medicine,
and a clinician at the San Ysidro Community Health Center in Chula Vista, Calif.
He received his medical degree from Harvard Medical School, Boston, and
completed a family practice residency at the Scripps Family Practice Residency
Program in Chula Vista, Calif.
Address correspondence to Ellen Beck, M.D., University of California, San Diego,
Department of Family & Preventive Medicine, 9500 Gilman Dr., La Jolla, CA 920930696 (e-mail: ebeck@ucsd.edu). Reprints are not available from the authors.

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often at night. Many attacks begin during


the first rapid-eye-movement sleep phase.
Patients may report a seasonal pattern, with
spring and autumn peaks.
Cluster headache is diagnosed by history,
and the key feature is a pattern of recurrent
bouts of near-daily attacks lasting for days,
weeks, or months. Patients fearing an attack
may be afraid to go to sleep. Precipitants
of cluster headache include hypoxia, which
may occur with sleep apnea. Vasodilators
such as nitroglycerin, alcohol, and carbon
dioxide may trigger a headache during a
cluster period.10
Although similar to cluster headache, paroxysmal hemicrania headaches are briefer and
are treated effectively with indomethacin.5
Orbital myositis may mimic cluster headache,
but the headache has a longer duration.
Etiology
Positron emission tomographic (PET) scanning and functional magnetic resonance
imaging are helping to clarify the poorly
understood etiology of cluster headache. The
basic pathophysiology is in the hypothalamic
gray matter.11 In some families, an autosomal
dominant gene may be involved, but calcium
channel activity or nitric oxide sensitivity
alleles have not been identified.12 Carotid
and ophthalmic artery vasodilation and an
increased sensitivity to vasodilator stimuli during an attack may be triggered by trigeminal
parasympathetic reflexes. Abnormal heart rate
variability and increased nocturnal lipolysis
during attacks and in remission reinforce the
theory of an autonomic function abnormality with increased parasympathetic drive and
decreased sympathetic function. Attacks often
begin during sleep, implicating a disorder of
circadian rhythm.13 An increased incidence of
sleep apnea in patients with cluster headache
suggests that periods of reduced oxygenation
of key tissues may trigger an attack.14
Treatment
Cluster headache treatment requires a dual
strategy. Acutely, the attack must be aborted
or subdued. Concurrently, prophylaxis is
initiated to suppress the recurrent headaches
expected throughout the remaining clusVolume 71, Number 4

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Cluster Headache
TABLE 1

Treatment of Acute Cluster Headache

Drug

Dosage and route

Oxygen

7 L per minute for


15 minutes via
face mask

Sumatriptan

Reported
adverse effects

Efficacy

Comments

None

In a double-blind crossover study15


of 19 patients, 56 percent reported
complete or substantial relief
compared with 7 percent in the
placebo group.

Treatment of choice

6 mg subcutaneously;
may repeat in
24 hours

Local skin reactions,


fatigue, nausea,
vomiting, dizziness,
chest symptoms,
throat symptoms,
burning sensations,
paresthesias

In a double-blind RCT16 of
49 patients, 46 percent were
free of pain within 15 minutes
compared with 10 percent in the
placebo group.
In an open study17 of 138 patients,
96 percent of attacks were relieved
at 15 minutes.

Contraindicated
in patients with
coronary artery
disease, uncontrolled
hypertension, or angina

20-mg nasal spray

None

In a double-blind RCT18 of
118 patients, there was a
57 percent response compared
with a response of 26 percent
with placebo. Pain-free rates at
30 minutes were 47 percent
compared with 18 percent with
placebo.

Intranasal
dihydroergotamine

0.5-mg nasal spray


bilaterally

None

In a double-blind trial19 of
25 patients, the severity of
attacks was reduced. There was
no effect on frequency or
duration of attacks.

Intravenous and
intramuscular routes
have been used, but
their efficacy has not
been substantiated in
controlled clinical trials.

Intranasal lidocaine

1 mL of 10 percent
lidocaine placed
with a cotton
swab bilaterally
for 5 minutes

Unpleasant taste

In a double-blind, placebo-controlled
trial20 of 15 patients, there was a
decrease in pain after 5 minutes,
and nine of nine treated patients
were free of pain at 35 minutes.

Place as close to
sphenopalatine fossa as
possible.

Intranasal capsaicin

Place via cotton swab


in ipsilateral nostril
twice a day for
seven days

Burning sensation
(decreases after
five applications)

In a double-blind, placebo-controlled
trial21 of 15 patients, there was a
reduction of headache severity in
the treatment group at eight to
15 days.

There were more patients


with episodic cluster
headache in the
treatment group and
more patients with
chronic headache in the
control group.

RCT = randomized controlled trial.


Information from references 15 through 21.

ter period; prophylaxis is continued for the


expected duration of the cluster period and
then tapered off. Patients with chronic cluster headache require long-term prophylaxis.
In patients with intractable headaches, more
aggressive intervention, including surgery,
may be required.
ACUTE OR ABORTIVE

The treatments of choice for acute cluster


headache are oxygen (7 L per minute for
15 minutes), sumatriptan, or a combination
of the two (Table 1).15-21 Both therapies appear
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to be underprescribed. Sumatriptan is available as a subcutaneous injection or as a nasal


spray.16-18 It is contraindicated in patients
with ischemic heart disease, uncontrolled
hypertension, or peripheral vascular disease,
and it should not be combined
with ergotamine. Tachyphylaxis
The treatments of choice
does not occur when the drug is
for acute cluster headache
used for long periods. Higher
attacks are oxygen, sumatsumatriptan doses (12 mg subriptan, or a combination of
cutaneously) were not found to
be more effective and had more
these treatments.
side effects than 6-mg doses.18
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TABLE 2

Prophylaxis of Episodic Cluster Headaches

Intranasal dihydroergotamine can reduce


attack severity, but it does not reduce attack
frequency or duration. This nasal spray has
fewer adverse reactions and better bioavailability than oral ergotamine.19 Intranasal lidocaine has been shown to decrease pain after
five minutes, with nine of nine treated patients
free of pain after 35 minutes.20 Intranasal
capsaicin, which is hypothesized to deplete
substance P from sensory nerve terminals, is
used in treatment of other pain states, including herpes zoster. In a study of patients with
cluster headache, it reduced the severity of
headaches after seven days of treatment.21
The effectiveness of melatonin is unclear
because of conflicting studies.22 Its role, if
any, will be in the initial prevention of
attacks, theoretically by resetting the circadian rhythm.
PROPHYLACTIC

Oral sumatriptan has not been shown to


be effective prophylactically.23 Verapamil in
dosages of 360 to 480 mg daily is one of the
few treatments for episodic cluster headache
tested in a randomized controlled trial (RCT)
and found effective in reducing attack frequency (Table 2).13,24-31 This treatment also
is underused, with only 4 percent of patients
with cluster headache reporting prophylactic
verapamil use.
Prednisone often is used in prophylaxis,
starting at a dosage of 50 to 80 mg daily and
tapered over 10 to 12 days. A 1975 study
that used a double-blind control methodology led to improvement in 17 of 19 patients
compared with placebo, but the study quality was limited.26 A recent nonrandomized study of cluster headache
prophylaxis that used three
Verapamil has demonstrated
days of 250 mg of intravenous
efficacy in the prophylaxis
methylprednisolone followed
of episodic cluster headache.
by a prednisone taper indicated
fewer headaches in the active
phase than with previous treatments in a
group of 14 men.32 In small studies, the antiepileptic drugs divalproex and topiramate
were found to be useful.28 Gabapentin and
baclofen have been tried with some success
in case reports and nonrandomized trials.28
However, no RCTs have been conducted to
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Drug

Dosage and route

Verapamil

120 to 160 mg orally three


times daily

Prednisone

50 to 80 mg orally daily
tapered over 10 to 12 days

Divalproex

600 to 2,000 mg daily

Topiramate

25 mg orally daily for seven


days, then increase dose
by 25 mg daily every week
to a maximum dosage of
200 mg daily

Ergotamine

2 to 4 mg daily in divided
doses

Methylergonovine
maleate

0.2 mg orally three or four


times daily

Melatonin

10 mg orally at bedtime

RCT = randomized controlled trial.


*Review article; original studies not referenced.
Information from references 13, and 24 through 31.

determine conclusively the effectiveness of


antiepileptic drugs.
Historically, ergotamine in a dosage of
2 to 4 mg per day has been a common agent
for episodic prophylaxis, but no RCT of oral
ergotamine has been reported. Ergotamine
and sumatriptan should not be taken concurVolume 71, Number 4

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Cluster Headache

Adverse effects

Efficacy

Comments
24

Hypotension, bradycardia,
atrioventricular block, dizziness,
fatigue, nausea, constipation

In a double-blind RCT of 30 patients, 12 of 15 patients


had a reduction in frequency of attacks within two weeks.
In a double-blind study25 of 30 patients who received
verapamil versus lithium, 50 percent of patients improved
during first week of treatment.

Increased appetite, insomnia,


nervousness, hyperglycemia,
dizziness, headache

In a double-blind study,26 17 of 19 patients experienced


improvement in pain, and the treatment group had a
lower frequency of headaches.
In a retrospective study,27 14 of 19 patients had more than
50 percent headache relief.

In trial,26 improvement occurred


within two days.
Recurrences often occurred toward
the end of the taper.27
Should take concurrently with
another prophylactic medication.

Nausea, somnolence, dizziness,


insomnia, anorexia, weakness,
thrombocytopenia, alopecia,
weight gain

In an open-label study,28 nine of 15 patients experienced


complete disappearance of pain, and two others
markedly improved.
In another open-label study28 of 26 patients, headache
frequency decreased by 54 to 59 percent.*
No RCTs.

Use caution in patients with renal


or hepatic insufficiency.

Paresthesias, cognitive effects,


drowsiness, dizziness

In a retrospective chart review29 of patients with


migraine and cluster headache, nine of 12 patients with
cluster headaches exhibited moderate to substantial
improvement. No RCTs.

Vertigo, pruritus, nausea, paresthesias,


weakness, cardiac valvular fibrosis,
retroperitoneal or pleuropulmonary
fibrosis, angina, myocardial
infarction; may cause withdrawal
symptoms if suddenly discontinued

No RCTs. Anecdotal evidence by experienced neurologist


suggests effectiveness.13

Best for nocturnal attacks;


contraindicated in peripheral
vascular disease, hypertension, and
cardiac disease; caution with renal
or hepatic insufficiency; should not
take concurrently with sumatriptan

Hypertension, nausea, vomiting,


diarrhea, leg cramps, dyspnea,
dizziness, tinnitus, nasal congestion,
diaphoresis, palpitations,
thrombophlebitis, hematuria,
water intoxication, abdominal
cramping, weight gain, paresthesias,
amenorrhea; hallucinations in high
doses

In a retrospective cross-sectional study,30 19 of 20


patients reported a decrease of more than 50 percent
in headache frequency; 15 of 20 patients reported a
reduction in headache intensity.

Caution in patients with peripheral


vascular disease, cardiac disease,
or renal or hepatic insufficiency;
only for use in refractory cases;
should never be used continually
for longer than six months;
contraindicated in pregnant and
hypertensive patients; possibility
of retroperitoneal, cardiac, and
pleuropulmonary fibrosis

None reported

In a double-blind, placebo-controlled study31 of 20 patients,


headache frequency was reduced in five of 10 patients in
the treatment group. A more recent pilot study19 of nine
patients did not show any difference in response between
the treatment and placebo groups.

rently. In addition, patients with peripheral


vascular disease should not take ergotamine.
A recent review summarizes management
guidelines for patients who continue to use
ergotamine or who cannot tolerate verapamil
or other prophylactic medications. Patients
who experience attacks at night may be given
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1- or 2-mg tablets orally or by suppository


before bedtime.13 When headaches start consistently at the same time each day, patients
may be advised to take ergotamine 30 to
60 minutes before the time of their usual
attack. A combination of verapamil and
ergotamine may be considered.13
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TABLE 3

Treatment of Chronic Cluster Headaches


Adverse effects
or complications

Generic
cost*

Drug

Dosage and route

Efficacy

Verapamil

120 mg orally three


times daily

Hypotension,
bradycardia,
atrioventricular
block, dizziness,
fatigue, nausea,
constipation

In an RCT of 30 patients,
12 of 15 patients had a
reduction in frequency
of attacks within two
weeks.25

Lithium

Start at 300 mg orally


three times daily;
use blood levels to
achieve therapeutic
dose.

Confusion, dizziness,
blurry vision,
diabetes insipidus,
headache, nausea,
polyuria

In a double-blind crossover
$11 to
study33 of 30 patients,
16 per
50 percent of patients
month
responded in two weeks.
In a more recent RCT,34 using
800-mg extended-release
tablets daily showed no
benefit over placebo.

Need close monitoring


of lithium levels; test
12 hours after last
dose; side effects
include tremor
and dysuria; check
thyroid and renal
function before and
during treatment.

Microvascular
decompression

NA

Infection,
cerebrospinal fluid
leak, postoperative
headache requiring
lumbar puncture

In a trial35 of 28 patients,
46 percent had success at
long-term follow-up.

Only used for


intractable cases

$20 to
46 per
month

NA

Comments

NA = not applicable; RCT = randomized controlled trial.


*Estimated cost to the pharmacist based on average wholesale prices in Red book. Montvale, N.J.: Medical Economics Data, 2004. Cost to the
patient will be higher, depending on prescription filling fee.
Information from references 25, and 33 through 35.

Methysergide previously was used for


cluster headache prophylaxis, but its use
has been discontinued in the United States
because it can cause retroperitoneal, cardiac,
and pleuropulmonary fibrosis. Methylergonovine maleate should be restricted to use in
refractory cases and should never be used for
more than six months continuously. Methylergonovine, probably the active metabolite
of methysergide, decreased cluster headache
frequency by more than 50 percent in 19 of
20 patients in a pilot study.32 Contraindications include hypertension and pregnancy.
Methylergonovine should be used with caution, if at all, in patients with cardiac or
peripheral vascular disease, or hepatic or
renal insufficiency. Hallucinations can occur
because it is a lysergic acid derivative.30
CHRONIC CLUSTER HEADACHE

Verapamil is used in the treatment of chronic


cluster hadache.24 Lithium has been used
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as long-term prophylaxis for years on the


basis of case series demonstrating effectiveness (Table 3).25,33-35 In an RCT of lithium
in episodic cluster headache, substantial
improvement occurred in both groups: six
(43 percent) of 14 patients in the placebo
group and eight (62 percent) of 13 in the
lithium group. The study, which was stopped
because superiority over placebo could not be
demonstrated, challenges physicians to look
at the positive treatment effect of placebo.34
SURGICAL OPTIONS FOR INTRACTABLE
HEADACHE

Microvascular decompression of the fifth


cranial nerve with or without section of
the nervus intermedius was performed in
30 patients.35 Initially, 77.3 percent of patients
experienced relief, but after five years, only
46.6 percent reported continued excellent or
good outcome. Repeat surgeries did not add
benefit. It is important to choose a surgical
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Cluster Headache

intervention that maintains nerve supply so


that facial numbness and corneal anesthesia
are less likely to occur.
NEW DIRECTIONS

Patients with severe snoring and cluster headache should be evaluated for sleep apnea. In
some patients diagnosed with sleep apnea,
treatment for apnea also proved to be effective for the headaches.14
Botulinum toxins A and B are being studied as treatments for various headaches, with
evidence of some efficacy and mixed reports
as to side effects. An ongoing study is addressing their role in chronic cluster headache.
A recent report35 described a patient with
intractable cluster headache; PET scanning
revealed activation of the posterior inferior
hypothalamic gray matter during attacks. A
stereotactic electrode was implanted in this
area, with a permanent generator placed in
a subclavicular pocket. When stimulation
was provided at a frequency of 180 Hz, the
attacks disappeared after 48 hours. Twice,
the stimulator was turned off without the
patients knowledge, and attacks returned
within 48 hours. The latter attacks disappeared 48 hours after the generator was
restarted. Thirteen months later, the pain
had not recurred.
Behavior and Lifestyle Interventions
Although little research has assessed the effectiveness of psychologic and behavior strategies on cluster headache, these approaches
have been supported in the management
of migraine and other chronic headaches.
Strategies that have proved effective for other
headaches target pain intensity and resultant
disability, analgesic overuse, adherence to
prescribed regimens, and psychiatric comorbidity. The difference between a functional
life with pain and a life of significant disability often is related to the patients ability to pace activities and regulate emotions
(thereby decreasing the fear of pain and
subsequent autonomic arousal), engage in
healthy behaviors, and function despite the
presence of pain.
To maximize the quality of life in patients
with cluster headache, strategies including
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relaxation, biofeedback, smoking cessation,


and alcohol intake reduction should be considered. The prevalence of cigarette smoking
is higher in patients with cluster headache
than in control patients. In one retrospective study,7 however, patients with cluster
headache who had stopped smoking did not
notice any change in their symptom pattern. Heavy alcohol use is more common
in patients who progress to chronic cluster
headache compared with those who have
episodic headache, although it is unknown
whether alcohol is a cause or result of living
with chronic pain.
Relaxation training paired with thermal biofeedback is effective in tension and
migraine headache treatment. Biofeedback
may be effective in patients with post-traumatic headache.36 For patients with cluster
headache and a history of head trauma or
migraine, these options may be considered.
If cluster headache is an autonomic disorder, biofeedback may be valuable. Cognitive
behavior interventions with proven value in
migraine treatment38 that may be considered
in patients with cluster headache include
discussing reasonable expectations, keeping
simple behavior diaries, and emphasizing
personal responsibility. Patients are taught
self-assessment and self-regulation skills
that help them challenge irrational beliefs
such as all-or-nothing thinking, catastrophizing outcomes, or attributional styles that
lead them toward ineffective strategies (e.g.,
I have no control over the pain). Providing
patients with ongoing compassion, knowledge about cluster headache, coping skills,
and a long-term trust relationship is crucial
in helping them cope with this difficult and
painful condition.
The authors thank Alicia Johnson and Carol BloomWhitener for administrative support and assistance in the
preparation of the manuscript.
Members of various family medicine departments
develop articles for Practical Therapeutics. This article
is one in a series from the Department of Family and
Preventive Medicine at the University of California, San
Diego. The coordinator of the series is Tyson Ikeda, M.D.,
director of the Family Medicine Residency Program.
The authors indicate that they do not have any conflicts
of interest. Sources of funding: none reported.

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American Family Physician 723

Cluster Headache

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Volume 71, Number 4

February 15, 2005